Descriptive Paraphilic Behaviors in the General Non-Clinical Population in Puerto Rico

Descripción de las Conductas Parafílicas en la Población General No-Clínica en Puerto Rico

Edward Fankhanel ^1*, Caleb Esteban ², Jorge Berrios ³, Frances Figueroa ⁴, María del C. Santos-Gómez ⁵, & Eliut Rivera-Segarra ⁶

Recibido: 3 marzo 2021 | Aceptado: 30 marzo 2021 | Publicado: 14 abril 2021

Fankhanel, E., Esteban, C., Berrios, J., Figueroa, F., Santos-Gómez, M. C., & Rivera-Segarra, E. (2021). Descriptive paraphilic behaviors in the general non-clinical population in Puerto Rico. Revista Caribeña de Psicología, 5, e5543. https://doi.org/10.37226/rcp.v5i1.5543

INTRODUCTION

This study seeks to gather basic descriptive data regarding the practices of paraphilic sexual behaviors in a non-clinical sample of persons living in Puerto Rico. Researchers have called into question the global inclusiveness in sexuality research, arguing that the limited evidence available has almost exclusively focused on developed countries, neglecting to address sexuality expressions and experiences in other diverse contexts, such as Latin America and the Global South (Bhugra et al., 2010; Dworkin et al., 2016). By studying paraphilic behaviors in other countries and cultures, science moves forward into identifying possible differences as to such expressions. If such differences exist, the way we address assessment, diagnosis, and treatment would need to be rethought accordingly. This study aims at providing some data as to how such behaviors occur in the Puerto Rican culture.

Research on paraphilias' prevalence among the general non-clinical population is scarce and varies substantially across generations, geographical areas, definitions, and data collection methods (Castellini et al., 2018; Joyal & Carpentier, 2016). Recent literature has begun to assess the limited evidence available critically and have posited that unlike what has been traditionally published; paraphilias are neither rare nor unusual among the general non-clinical population (Castellini et al., 2018; Joyal & Carpentier, 2016). For example, some research suggests that paraphilic fantasies and behaviors could be quite familiar with the prevalence estimates ranging from 44% to 52% for at least one paraphilia among the general population (Alhers, 2011; Olivera & Abdo, 2010).

The Diagnostic and Statistical Manual of Mental Disorders, last edition (DSM-5), has estimated the prevalence of 12% for voyeuristic disorders, between 2% to 4% for exhibitionistic disorders, and 3% to 5% in pedophilia, while the prevalence of other paraphilias is not well documented to date (American Psychiatric Association, 2013). However, a more recent study in Nigeria, a non-western culture, reported just 8.7% prevalence for voyeurism, 1.6% for exhibitionism, and 0.5% for pedophilia (Abdullahi et al., 2015). Another study conducted in Germany found that 0.1% of participants indicated having pedophilic sexual preferences, but 4.1% indicated having sexual fantasies towards prepubescent children, while only 3.2% did engage in sexual activity with prepubescent children (Dombert et al., 2015).

Paraphilias

A paraphilia is generally defined as a persistent sexual interest in an atypical target (i.e., clothing) or activity (i.e., looking at another person) that is necessary for sexual enjoyment (Dawson et al., 2016). According to the DSM-5, a paraphilic disorder is a mental illness in which a person experiences significant distress or impairment in a domain of functioning resulting from their recurrent intense sexual fantasies, urges, or behaviors generally involving an unusual object, activity, or situation (American Psychiatric Association, 2013; Balon, 2013). Thus, paraphilia is a necessary but not sufficient condition for diagnosing a paraphilic disorder, and paraphilia by itself does not necessarily justify or require clinical intervention as it is not necessarily a pathology (American Psychiatric Association, 2013).

The DSM-5 specifically states that “in a clinical interview or on self-administered questionnaires, examinees can be asked whether their paraphilic sexual fantasies, urges, or behaviors are weaker than, …their normophilic sexual interests and behaviors” (American Psychiatric Association, 2013, p.686). Making the distinction between fantasies, urges or behavior may be critical in treatment planning should an individual require counseling or psychotherapy. A clear differentiation as to these three activities can be seen in the study by Dombert et al. (2015), which reports differences in sexual offenders who only fantasize about their sexual desires versus those who engage in them.

Regarding the classifications of paraphilic sexual activities, the DSM-5 specifically defines eight paraphilias (Voyeuristic, Exhibitionistic, Frotteuristic, Sexual Masochism, Sexual Sadism, Pedophilic, Fetishistic, and Transvestic) with the possibility to include others under the diagnostic category of – “Other Specified Paraphilic Disorders - 302.89” (American Psychiatric Association, 2013, p.705). As such, the need to expand the possibilities beyond the eight specifically defined paraphilias should be considered when seeking data as to normophilic versus paraphilic sexual interests in a specific culture, since conventional sexual stimuli (normophilia) can vary within a specific culture and era in which individuals are raised or reside (Moser & Kleinplatz, 2020).

A review of the literature presents an extensive list of paraphilias. From the DSM-5 list of eight specifically described paraphilias (American Psychiatric Association, 2013), through Money’s (1984) listing of 32 and up to 547 by Aggrawal (2009). This makes the selection process of what paraphilic activities to include in a study quite difficult. To decide by just relying on studies from other cultures would diminish the possibilities of identifying differences across cultures. On the other hand, the limitation or unavailability of studies in a specific group or culture brings up the question of which to include in a descriptive exploratory study such as this one. Puerto Rico is the smallest of the Greater Antilles and a non-incorporated territory of the United States located east in the Caribbean Sea. A country with marked Hispanic influences (i.e., Spanish language, Catholicism, etc.), the population of Puerto Rico is estimated at 3.2 million (US Census Bureau, 2018). Despite the cultural diversity of the Puerto Rican context and its potential to inform sexuality research transnationally, research on paraphilic sexual behaviors in non-clinical populations on the Island is limited.

The reviews of scientific literature available reveal that the first and, up to date only population-based study describes multiple sexual behaviors among adults ages 21 to 64, however not including paraphilic activities but, risky sexual behaviors such as anal intercourse, sex without protection, multiple sex partners, drug use, among other (Ortiz et al., 2011). Within the Puerto Rican gay community, a study on gay youth behavior during the coming out process, which only asked about high-risk sexual activities for HIV/STD transmission, did include a question on cybersex/phone sex in which 45.2% responded to engage ‘sometimes’ and 6.9% reporting ‘always’ (Fankhanel, 2010).

The only study found in the literature to address paraphilic behavior in Puerto Rico was conducted among a sample of gay men (Fankhanel et al., 2011). The participants (n=429) from across the entire Island were asked to report lifetime frequency of sexual fantasies, urges, or behaviors (never, one time, two to ten times, 11 to 20 times, 21 or more). Among the list of 21 atypical sexual activities asked, participants most reported engaging 21 or more times in Exhibitionism (9.7%), Voyeurism (8.4%), Fetichism (4.4%), Frotteurism (1.7%), Pedophilia (0.7%), Sexual Sadism (0.6%), and Sexual Masochism (0.6%). A question regarding observing erotic films or pictures was also asked, of which 50.8% reported doing so ‘21 times or more. The study included questioning participant's sexual preferences with persons outside their age group range; specifically, 17.1% reported preferences towards persons at least ten (10) years older, and 9.3% towards persons at least ten (10) years younger.

However, similarly to sexuality research worldwide, a limitation of this previous study is the emphasis on behaviors while neglecting to examine fantasies, urges, or any combination. Thus, in order to better understand the spectrum of possible responses to paraphilias and paraphilic disorders, research needs to document these distinct components of paraphilic interests (fantasies, urges, or behaviors), particularly among culturally diverse populations such as Puerto Ricans, as it may constitute a significant variable when conducting psychological assessments for treatment planning.

Purpose of the Study

This study aimed to obtain descriptive data pertaining to paraphilic sexual activities among a non-clinical sample of persons living in Puerto Rico. As the only current study in Puerto Rico addressing paraphilic behaviors was conducted in the gay population (Fankhanel et al., 2011), the questionnaire in the said study was used to select and modify questions to address the more heterogenic population of this study. Of special interest to the investigators is to identify if participants report differences between fantasies, urges, or behaviors of a specific paraphilia. This would inform us as to the specific type of response (fantasy, urge, or acted out behavior) the participants engage in, and more specifically, which are acted out, as documented by the study of Dombert et al. (2015). Furthermore, we want to explore if there is a relationship between the fantasies reported and behaviors; this data would be beneficial when conducting psychological interventions such as counseling and psychotherapy.

Because it is a descriptive exploratory study, it was decided that participants would be asked to mention the paraphilic fantasies, urges, or behaviors they experienced only during the last six (6) months prior to the study. This would allow some inferences as to a possible connection between the development, or expression of the three categories (fantasy, urge, behavior), in a specific paraphilia. Another aim of this study is to ask participants about their sexual fantasies, urges, or behaviors in other atypical sexual behaviors that could be included in the DSM-5 diagnostic category of – Other Specific Paraphilic Disorders -302.89, which currently includes examples such as telephone scatologia (obscene phone calls), zoophilia (animals), klismaphilia (enemas), and others. (American Psychiatric Association, 2013). Therefore, as used by Fankhanel et al. (2011) in the gay population of Puerto Rico, the use of pornography, as well as questioning sexual activity towards persons at least ten years younger or older, were included.

As to pornography, the American Psychological (n.d.) has defined Pictophilia as a “sexual interest in and arousal by viewing erotic pictures or films, alone or with a partner.” Hopkins et al. (2016) state that “Pictophilia is a dependence on watching pornographic tapes or pictures…” (p.5). This implies that the act of viewing erotic pictures or films over any internet media may well fall under the category of pornography, defined by Jenkins (n.d.) as a representation of sexual behavior in motion pictures and other media that is intended to cause sexual excitement.

Hopkins et al. (2016) have stated that “More recently, voyeurism, and exhibitionism for that matter, have evolved to incorporate web-based activities, giving rise to sites and services dedicated to voyeuristic and exhibitionistic pursuits, and also resulting in misuse of social networking services…argues that the construct of voyeurism goes well beyond the sexual, paraphilic meaning traditionally considered, describing the increasingly voyeuristic nature of entertainment and communication in our culture” (p.5). As pornography research is on a rise (Mead et al., 2018), it seems justifiable to include pornography in paraphilic activity studies.

Another area of interest for the investigators is the sexual attraction to age-specific groups. Pranzarone (n.d.) defines Chronophilia as one of a group of paraphilias of the stigmatic/eligibilic type in which the paraphile's sexuoerotic age is discordant with his/her actual chronological age. Examples of Chronophilia would include infantilism, pedophilia, ephebophilia, and gerontophilia. Others mention the term chronophilia as referring to “age discrepancy” (Fedoroff, 2016, p.351) and to a paraphilia related to age/maturity categories other than young sexually mature adults (Seto, 2017), and “Arousal from the passage of time, arousal from an older partner” (Aggrawal, 2009, p.372). However, although chronophilia is mentioned in the literature, research on specific age groups outside pedophilia is limited. In Puerto Rico, Fankhanel et al. (2011) included a question for gay men to indicate the number of times they had experienced sexual fantasies, urges, or behaviors towards persons either ten (10) years younger or older, which would be outside their age group but not group-specific, this study seeks to see if such behavior is reported among the heterogeneous population of Puerto Rico.

Thus, the specific objectives of this study were: 1) describe paraphilic sexual activities in Puerto Rico, identifying differences between fantasies, urges, or behaviors of specific paraphilias, 2) explore if there are relations between sexual fantasies and acting out (behavior) those fantasies, 3) explore the satisfaction with their lives, mental health and worries about the sexual behavior of those who report paraphilic behaviors, and 4) describe the feelings during and after having atypical fantasies, desired and/or behavior.

METHOD

Research Design

The authors implemented a quantitative method with a descriptive cross-sectional design using survey techniques via an online platform.

Participants and Procedure

After obtaining approval from the first author’s Institutional Review Board (IRB), we proceeded to announce the study and collect the data. Data was collected via the online platform SurveyMonkey. To recruit participants from around the island of Puerto Rico, announcements were made on social media such as Facebook and through the University’s web page. The three leading newspapers in Puerto Rico were approached, of which one accepted to write an article on the study and encouraging participation. A snowball recruitment effect was also used. All announcements were approved by the IRB and expressly indicated that the study was about atypical sexual behaviors, and participation was anonymous.

The announcement consisted of asking people over the age of 21 to respond to a survey of atypical sexual behaviors anonymously to ensure participant's privacy while responding to the questionnaire, enhance social desirability and foster a higher validity rate in the responses. We used a non-probabilistic sampling procedure to collect the quantitative data. A total of 1,581 respondents living in Puerto Rico at the time completed the survey. After the removal of incomplete surveys, a total of 1,255 participants remained. The sample consisted of 51.8% male, 48.0% female, and 0.1 % transgender. The average age was 30-39 years old (25.5%). Most identified themselves as Hispanic (86.3%), while 8.7% identified as White, 1.5% as Black, and 3.6% as other. In terms of religious affiliation, participants identified themselves as Catholics (42.2%), non-religious (31.9%), Evangelicals (12.5%), Protestants (10.5), and others (2.6%). Regarding their social class, participants identified themselves in the following categories: 5.1% lower class, 23.4% middle-lower class, 51.4% middle class, 17.9% middle-upper, and 2.2% upper class. Heterosexual orientation was reported by 81.7%, while 9.1% identified as gay men, 7.3% as bisexual, and 1.7% as a lesbian. Most of the sample had a university education (78.2%), and 37.5% were married.

Measures

Paraphilic Behaviors Questionnaire. This instrument is an adaptation of the Spanish language questionnaire used by Fankhanel et al. (2011) to identify paraphilic behaviors among a group of gay men in Puerto Rico (57 items). Changes and modifications of such questionnaire included the possibility of a participant to specifically indicate and differentiate among sexual fantasies (a mental image or a series of mental images (such as a daydream and dreams), sexual urges (all of the feelings resulting from the urge to gratify sexual fantasy impulses), and sexual behaviors. Other changes included eliminating or adapting gay sexual lifestyle specific variables not applicable to the general population. To seek information on other atypical sexual behaviors, we added other possible sexual activities such as pornography (Hopkins et al., 2016). The study of sexual desires towards minors has been the focus of most studies regarding pedophilia. Of interest to the investigators of this study is to question the sexual interest towards persons outside the participant age group as was asked to the gay people in Puerto Rico for comparison purposes. As such, a question about such sexual interest in persons at least 10 years older than the respondent was included. The 78 items questionnaire is divided into 1) general demographics, 2) specific sexual behaviors, and 3) psychological variables.

A total of 14 sociodemographic questions were asked, followed by the specific sexual behavior section, which included a description (not the name/term) of the paraphilic behaviors provided in the DSM-5. Following these, other specific paraphilic behaviors included in the questionnaire were: (1) use of feces, (2) sex with animals, (3) observing your partner have sex with others, (4) the use/observation of pornography, (5) asphyxiophilia, (6) specific body parts, (7) enemas, (8) urine/golden-showers, and (9) sex with a person at least 10 years older.

This section was subdivided into three categories: (1) during the last six months, have you had any fantasies in these areas? (2) during the past six months, have you experienced any sexual urges in these areas? (3) during the last six months, have you engaged in sex in these areas? Participants were provided with a response scale with the following categories: never, rarely, frequently, and frequently. By separating sexual fantasies from sexual urges and sexual activities, participants had the opportunity to respond accordingly. The questionnaire also includes questions to explore their satisfaction with lives, mental health, and worries about their sexual behavior. The last section of the survey includes two questions with options addressing participants' mental and emotional state due to such sexual fantasies, urges, or behaviors; they could select all that applied. Those options were asked, specifically during and after the experience. Participants were given 17 options, seven positives (relaxed, calmed, satisfied, fascinated, peaceful, indifferent, excited), nine negatives (depressed, hopeless, scared, guilty, empty, alone, sinning, sick, embarrassed), and do not apply. Options were converted to dichotomous responses, and each was dichotomized such that a value one indicated the presence of the emotion and was not present. Then we regroup the option into two summed variables: positives and negatives emotions, whereby a higher score indicated more positive or negative emotions.

Data Analyses

Descriptive statistical analyses were conducted using SPPS (v.23) to generate the percentages of paraphilic sexual fantasies, urges, or behaviors reported by the participant. Answers were recategorize never = never, almost never & sometimes = sometimes, and frequently & and very frequently = frequently (Table 1). Pearson Correlation was used with raw data to build the Correlation Matrix, using a significant point of .05 as suggested by the literature (Table 2). Only correlations with a medium effect (>.30) or more were highlighted. Descriptive statistics were also used to describe the satisfaction with their lives, mental health, and worries about the sexual behavior of those who reported paraphilic behaviors (Table 3), as well as to examine the presence of feelings during and after having atypical fantasies, desired or behavior of those who report paraphilic behaviors. To simplify the data, those who reported the behavior at some point (1-almost never to 4-frequently) were recategorized as reporters (Table 4).

RESULTS

For the first objective, most of the respondents (87.6%) reported at least one sexual fantasy, urge, or behavior from those paraphilic activities examined explicitly in this study. Also, participants reported differences within the same paraphilic interest regarding fantasies or urges, or behaviors. For example, regarding watching pornography (the most frequent of all paraphilic interests in this sample), 88% reported fantasizing about watching pornography at some point. In comparison, 84% indicated having the urge, and 78% engaging in the behavior at some point. The same was observed in other paraphilic interests. All paraphilias had higher rates of fantasies, followed by less frequent urges and even fewer behaviors. Coprophilia, sex with a person under the age of 13, Zoophilia, Transvestism, and Klismaphilia were the least reported paraphilias (see Table 1).

For the second objective, correlations analyses between sexual fantasies and behaviors (Table 2) showed a significant correlation (r > .30) between voyeurism with exhibitionism (.39), frotteurism (.32), watching your partner have sex with others (.38), and watching pornography (.40). Other significant correlations found included: Masochism with sadistic behavior (.49) and fantasies (.59). Partialism with fetishistic behaviors (.31) and watching pornography fantasies (.42) were also significant. Finally, urophilia was related to sadistic (.31) and klismaphilia fantasies (.36).

The third objective presents participant’s overall satisfaction with their lives. Satisfaction was reported by 81% or above as to those who informed a paraphilic behavior except for those who reported fetishism (79%) and urophilia (77%). As to perceptions regarding their mental health status and its relation to their reported atypical sexual behaviors, participants rated satisfaction (80% or above) for all behaviors except for klismaphilia (77%). When asked about participant’s worries about their sexual behaviors, 74% of those who reported transvestism indicated not to be worried versus the rest who reported 81% or above (see Table 3). Our last objective found that more people present positive feelings during (2%-37%) and after (3%-27%) having atypical fantasies, desired or behavior when compared with those who reported negative feeling during (.6%-4%) and after (.7%-5%) (see Table 4).

DISCUSSION

This study's objective was to document the fantasies, urges, and behaviors among a non-clinical population in Puerto Rico. Also, the investigators examined the reported sense of well-being concerning such paraphilic interests. Although descriptive and limited, the results address a vital research gap regarding paraphilic interests among non-clinical samples in culturally diverse contexts across the world.

This study's novel finding is regarding the separation and differentiation between fantasies, urges, and behaviors seldom examined in previous research on paraphilias among non-clinical samples. This information allows for a better understanding of the prevalence of these specific activities. It underlines the importance of differentiation in psychological analysis of pathological and non-pathological during clinical assessments.

This study examined paraphilias such as coprophilia, zoophilia, watching partners have sex with others, asphyxiophilia, partialism, klismaphilia, and urophilia. Four specific paraphilic interests (partialism, watching your partner have sex with others, asphyxiophilia, and urophilia) were particularly salient, ranging from 10%-59% of the sample reporting fantasies urges and ranges from 7%-44% reporting behaviors.

Additional findings include the frequency of paraphilic fantasies, urges, or behaviors experienced at some point in participant’s lives was higher among this sample (88% reported at least one paraphilic fantasy) than that reported by previous literature 44%-52% (Alhers, 2011; Joyal & Carpentier, 2016; Olivera & Abdo, 2010). These results might be partially explained by literature suggesting that people participating in sex-related research might generally be more sexually open (Wiederman, 1999). However, other factors might also be necessary. For example, most of this sample (78%) had some higher education level compared with the general Puerto Rican population, of which 25.3% have a bachelor’s or higher degree (US Census, 2019). This has also been linked to sexuality openness (Arhold et al., 2011; Joyal & Carpentier, 2016). The inclusion of paraphilic interests less stigmatized today (i.e., watching pornography), as well as the anonymity provided through the online survey, could have led participants to answer more openly, as well.

These findings provide information regarding a tendency to have higher rates of fantasies, followed by urges, and lastly by behaviors. However, these results also suggest significant differences between fantasies, urges, and behavior in the same paraphilic interest. These results also suggest that the gap between fantasies, urges, and behaviors are not the same for all paraphilic interests. For example, even though only 1% of the sample reported coprophilia fantasies, all those who answered affirmatively also had urges and engaged in the behavior. This could suggest that for some paraphilic interests, engaging in such behavior is preceded by fantasies and urges. A critical point in psychological assessments and treatment planning.

In general, findings were aligned with the literature in other contexts, and people tended to report more fantasies and fewer behaviors. Research has posited that societal and cultural factors and personality traits could partially explain results such as this one (Bhugra et al., 2010). However, there is still a need to examine what specific factors foster or hamper carrying out a fantasy or urge in a given cultural context.

Another finding was the correlation between voyeurism fantasies and other paraphilic fantasies (exhibitionism, frotteurism, watching a partner have sex with another, and watching pornography) and the correlation between sadism with masochism. These results are congruent with DSM 5 (American Psychiatric Association, 2013) paraphilic classifications such as courtship disorders, including exhibitionism and voyeurism, and algolagnic disorders, including masochism and sadism. This finding suggests psychological interest in such similar activities.

Much has been studied about pedophilic desires and behaviors in all cultures; however, no research measuring sexual desires insignificant older persons was found. This study shows 4% reporting sexual fantasies or urges and 1% behaviors in persons under the age of 13, which is congruent with pedophilic activities as reported in the DSM 5 (American Psychiatric Association, 2013). Having sexual fantasies urges or behaviors with a person at least ten (10) years older were included in this survey with the intent to measure the opposite side of the spectrum of age in sexual desires. Participants indicated interest in sexual activities with persons at least ten (10) years older. Specifically, fantasies were reported by 49%, urges by 46%, and behaviors by 25% of the participants. In the study of gay men in Puerto Rico, 79.3% of participants reported having at least one sexual fantasy, urge, or behavior with persons at least ten (10) years older, and 30.8%, at least ten (10) years younger (Fankhanel et al., 2011). This finding may serve to motivate further study in the area of chronophilia

Most participants in our sample reported a general sense of well-being with their lives and mental health. Also, most were not worried about their fantasies, urges, or behaviors. These results suggest that despite the generally conservative cultural context in which participants were embedded, their sexual fantasies, urges, and behavior, being paraphilic or not, do not seem to be a source of psychological distress.

Puerto Rican culture has traditionally been identified as Christian. This compares with the findings of this study, where most respondents were Catholic (42.2%), Evangelicals (12.5%), or Protestants (10.5). Morales’ (2018) findings reveal that religiosity does not necessarily hamper practicing paraphilic fantasies, urges or behaviors. Further analysis is recommended to understand better the link between such beliefs and paraphilic activities and their psychological implications. Further studies could address in-depth information as to spiritual beliefs, religion, and the perception of “wrong” versus “right” in paraphilic sexual practices today (Morales, 2018).

Being a Latino culture with high Christian values, Puerto Rican values, as an ethnic group, differentiates from the multicultural, multireligious faiths enmeshed in the Continental United States. As such, the optics from which sexual values, norms, and expected behaviors are expressed could deviate from those found in the Continental United States. The findings of this exploratory study may hopefully open the door to explore these differences and similarities further.

Despite some novel findings, there are some limitations in this study that need to be taken into consideration when interpreting these results. First, participants were not randomly nor probabilistically assigned; thus, these results are not representative of the Puerto Rican population. Secondly, due to the nature of the questionnaire and this study's aim, only descriptive analysis was conducted, which could limit the analysis of potential predictors or mediating variables regarding paraphilic sexual fantasies, urges, and behaviors. Finally, although online surveys could be an effective technique in this type of study as it offers anonymity, participants' self-report nature could be used by participants responding misleadingly. However, despite all the limitations, these results can inform future research as it provides novel empirical evidence about atypical sexual fantasies, urges, and behaviors in a culturally diverse context.

Financiamiento: La presente investigación no fue financiada por alguna entidad ni patrocinador.

Conflicto de Intereses: No existen conflictos de intereses de parte de los autores de la investigación.

Aprobación de la Junta Institucional para la Protección de Seres Humano en la Investigación: IRB de la Universidad Ana G. Méndez, Gurabo, Puerto Rico.

Consentimiento o Asentimiento Informado: Todo participante completó un consentimiento informado.

Proceso de Revisión: Este estudio ha sido revisado por pares externos en modalidad de doble ciego.

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